NDIA Accountability Project

SUBMISSION to the Community Development and Justice Standing Committee Legislative Assembly of Western Australia Inquiry into the Guardianship and Administration System in Western Australia

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SUBMISSION

to the
Community Development and Justice Standing Committee
Legislative Assembly of Western Australia
Inquiry into the Guardianship and Administration System
in Western Australia

Richard Graham
Principal
Graham & Associates Lawyers
Suite 1, 141 Broadway, Nedlands WA 6009

29 May 2026

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Table of Contents

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Office of the Public Advocate ……………………………………………………………………… 13
Public Trustee ………………………………………………………………………………………………….. 14
Dispute Resolution and Complaints ……………………………………………………………………… 14
State Administrative Tribunal ……………………………………………………………………… 14
Oversight and Monitoring ……………………………………………………………………………………. 15
Restrictive Practices …………………………………………………………………………………………….. 15
Conclusion …………………………………………………………………………………………………………….. 15

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Executive Summary

I am the Principal of Graham & Associates Lawyers, a legal practice with a substantial guardianship and administration caseload before the State Administrative Tribunal. This submission draws on my experience across matters conducted from 2016 onwards and is offered at a systemic level, without reference to any individual client matter.

The submission addresses each of the inquiry’s terms of reference. Its central observation is that the guardianship and administration system is under-resourced for the volume and significance of the decisions it makes, and that this strain produces recurring structural problems rather than isolated failures.

Five themes recur. First, the quality and balance of investigation reports is variable, and a more balanced approach to interviewing witnesses would assist. Second, notification and service processes depend on information from applicants who may have an interest in excluding family members, and materials are frequently served too close to the hearing. Third, there is no adequate systematic mechanism for monitoring guardians after appointment. Fourth, the system often responds to crises rather than preventing them. Fifth, the framework for consent to restrictive practices, including chemical restraint in residential aged care, does not adequately distinguish a restrictive practice from a medical treatment decision.

The submission also identifies structural power imbalances that the system does not adequately address.

The recommendations are set out in full in Part J. In summary, they seek a balanced investigation protocol, external audit, and a decisions portal at the Office of the Public Advocate; minimum service periods for hearing materials; direct Public Trustee contact with represented persons and an advance estimate of its fees before appointment; mandatory post-appointment monitoring; additional resources for the guardianship division; a clearer distinction between restrictive practices and medical treatment decisions; and express recognition of the NDIS within the Act.

I would be happy to appear before the Committee, and to provide any further information that would assist.

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Part A: Introduction

About the Author

  1. I am the Principal of Graham & Associates Lawyers, a legal practice based in Nedlands, Western Australia, with a caseload in guardianship and administration law before the State Administrative Tribunal. My practice represents applicants, respondents, family carers, and interested parties across a range of matters.

  2. I have appeared at more than 400 guardianship hearings before the Tribunal. I have presented at eight continuing professional development seminars on guardianship and administration to lawyers and others, including for the Law Society of Western Australia, LegalWise, and the Aboriginal Legal Service. I maintain a regularly updated blog on guardianship and administration decisions on my firm’s website. My practice receives approximately 350 enquiries from potential guardianship clients each year, through the website and by telephone.

  3. This submission draws on my direct experience across multiple guardianship and administration matters conducted from 2016 onwards. The observations and recommendations are offered constructively and with respect for the difficult and important work performed by the State Administrative Tribunal, the Office of the Public Advocate, and the Public Trustee. The Members, officers, and staff within these institutions operate under resource constraints and volume pressures, and their commitment to the welfare of vulnerable Western Australians is acknowledged.

  4. This submission does not identify any specific client matters. All observations are presented at a systemic level, informed by my experience.

Scope of Practice Experience

  1. The matters informing this submission have involved applications for the appointment of guardians and administrators, applications for review under section 17A of the Guardianship and Administration Act 1990 (WA), applications for leave to apply for review under section 87, appeals to the Supreme Court, interim applications under section 35(1) of the State Administrative Tribunal Act 2004 (WA), and disputes concerning enduring powers of attorney and guardianship. The represented persons have included elderly persons with dementia, younger persons with intellectual disability, persons with mental illness and co-occurring substance use disorders, and Indigenous persons in regional Western Australia.

Part B: Organisational Capability of the Public Trustee and the Office of the Public Advocate (ToR 1)

Investigation Processes

  1. The Office of the Public Advocate performs an essential function in the guardianship system. Its investigators are frequently the Tribunal’s primary source of independent information about the circumstances of the represented person.

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  1. My experience suggests that the quality and balance of OPA investigation reports can be variable. Two structural concerns arise. First, the current framework does not appear to require investigators to contact witnesses identified by the subject or by interested parties. Where investigators rely excessively on information provided by the applicant, the resulting report may not reflect the full picture. Second, the setting in which interviews with the represented person are conducted can affect the reliability of the person’s expressed wishes. An interview conducted in the presence of a person with an interest in the outcome may not accurately capture what the represented person would say in a neutral environment.

  2. No criticism is intended. It is obvious that investigators must make choices about whom to interview, and those choices reflect the time and resources available to them rather than any want of care. I also receive feedback that a witness is sometimes contacted by telephone, is unavailable when the call is made, and a message is left; a series of missed calls and messages can then follow, so that the witness is never interviewed before the report is finalised and provided to the Tribunal.

  3. These observations point to the value of a general principle that investigators take a balanced approach to interviewing witnesses, making efforts to hear from those identified by the applicant, the subject, and any interested parties, rather than relying mainly on the applicant, and that interviews with the subject be conducted in neutral settings wherever practicable. Investigators may also wish to consider using audio recording and voice recognition to improve the efficiency of the process and to allow a wider range of people to be interviewed within the time available.

Timeliness of Investigation Reports

  1. I have experienced matters in which OPA investigation reports were completed close to the hearing date, leaving participants with inadequate time to consider and respond to the findings. This difficulty falls most heavily on unrepresented participants, who may need additional time to understand the report and prepare a response.

  2. A minimum period of three working days between service of the investigation report and the hearing date would provide a more meaningful opportunity for participants to exercise their ‘right of reply’.

Transparency of Delegated Guardian Decisions

  1. When the Public Advocate is appointed guardian, decisions are made by delegated officers rather than by a person known to the represented person or their family. In my experience, represented persons, family members, and treating practitioners are often unable to ascertain what decisions the delegated guardian has made, or the reasons for them. The resulting lack of visibility fuels mistrust, generates avoidable disputes, and can leave treating practitioners without the context they need to provide continuity of care.

  2. The Committee may wish to consider whether the Office of the Public Advocate should establish a secure online portal, with levels of access that vary according to the role of the user, recording each decision made by the delegated guardian and the reasons for it. Access could be granted to the represented person, to family members, and to

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medical practitioners involved in the person’s care, with the information available to each user calibrated to their role. Such a portal would improve transparency, support continuity of care, and provide a mechanism of accountability for decisions that affect the represented person’s life.

The Public Trustee’s Relationship with Represented Persons

  1. My experience raises a question about the extent to which the Public Trustee maintains direct contact with represented persons following appointment as administrator. I have received feedback from people who are the subject of administration orders that they do not know who their trust manager at the Public Trustee is, beyond a generic email address, and that they find this dehumanising.

  2. A requirement for the Public Trustee to make and record reasonable efforts to meet with each represented person within a defined period after appointment, whether in person or by video, and to maintain periodic direct contact thereafter, would strengthen the quality of administration.

Part C: Organisational Culture (ToR 2)

Institutional Influences and the Investigation Function

  1. I have observed that OPA investigations can come across as overly responsive to institutional influence – particularly from hospitals seeking to discharge patients or resolve disputes with family guardians. This is not a criticism of individual investigators, and any such tendency is subconscious rather than intentional. Social workers at hospitals, who understandably carry the task of clearing hospital beds, bring an institutional imperative of which investigators are clearly conscious. The structural incentives of the system – the volume of matters, the urgency of hospital applications, and the institutional relationships between the OPA and the health system – may create an organisational culture that can favour resolution over more important factors.

  2. Periodic external audit of the OPA’s investigation function, including file reviews to assess balance and quality, would provide a safeguard. The Committee may also wish to consider whether a dedicated ombudsman for guardianship and administration should be available, rather than relying on the general Ombudsman of Western Australia.

Fee Proportionality

  1. The Public Trustee’s fees are set by a published scale of fees, which already includes measures directed at the proportionality of fees to the value of an estate. A difficulty is that the likely cost of the Public Trustee’s administration is seldom quantified before the appointment decision is made. The Committee may wish to consider whether, before the Tribunal decides whether to appoint the Public Trustee as administrator, the Public Trustee should provide an estimate of its likely fees for the estate. The purpose of the estimate would be to allow the cost of the Public Trustee’s administration to be weighed explicitly against the size and circumstances of the estate, so that, for a modest estate in particular, the proportionality of those fees can be assessed before the appointment

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is made. It might be said that an estimate would be too complicated to prepare; that difficulty could be met by requiring the estimate to relate only to the first year of administration where a longer prediction would be impractical.

Part D: Complaint, Dispute and Allegation Mechanisms (ToR 3)

Disputes Between Joint Guardians

  1. The enduring power of guardianship framework permits the appointment of multiple joint guardians, but the Act provides no statutory mechanism to resolve disputes between them. Where joint guardians disagree, the only available remedy is a fresh application to the Tribunal to vary or revoke the appointment – an expensive, time-consuming, and adversarial process that is disproportionate to many of the disputes that arise.

  2. The Committee may wish to consider whether the Act should provide a streamlined dispute resolution mechanism for joint guardians, such as mandatory mediation or conciliation, before formal Tribunal proceedings are required.

Aged Care Complaints and Guardianship Proceedings

  1. A concerning dynamic can arise when families who raise legitimate concerns about the standard of care in residential aged care facilities find those complaints characterised as adversarial or obstructive conduct in subsequent guardianship proceedings. This creates a perverse incentive: families who question care standards risk having their advocacy used against them as evidence of unsuitability.

  2. The Committee may wish to consider whether the Act should include a provision expressly protecting persons who make aged care complaints or engage with the Aged Care Quality and Safety Commission from having those complaints relied upon as evidence of unsuitability in guardianship proceedings.

Part E: Accessibility of Information (ToR 4)

Service of Hearing Materials

  1. I have consistently observed that submissions and evidence from interested parties are served at short notice before hearings. Where investigation reports are completed only days before a hearing, or where the entirety of a proceeding is compressed into a matter of weeks, the right to be heard is diminished. This difficulty falls most heavily on unrepresented participants.

  2. The Committee may wish to consider whether the Tribunal’s practice directions should prescribe minimum service periods for submissions and investigation reports, with a minimum of three working days before the hearing date.

Unrepresented Parties

  1. Approximately 7,500 guardianship and administration applications are made in Western Australia each year. My experience suggests that the proportion involving legal

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representation is small. The system is, in practice, an unrepresented person’s system – yet it operates under formal legal frameworks that assume a level of legal literacy that most participants do not possess.

  1. The complexity of the system can lead to participants agreeing to orders without fully understanding the scope of the authority being conferred, or without placing relevant information before the Tribunal. The Committee may wish to consider whether the Tribunal should be required to provide a plain-language explanation of the effect of proposed orders before they are made, and to confirm on the record that the participants understand what is being ordered. Options for improving understanding in advance could include short explanatory videos that set out the process, emailed to applicants, subjects, and interested parties, or intake sessions conducted by designated staff and delivered by video to a group at a time. Neither would require the time of Tribunal Members.

Communication by the Public Trustee

  1. Where the Public Trustee administers an estate without direct communication with the represented person, a structural information gap arises. The Committee may wish to consider whether the Public Trustee should be required to provide annual statements in a format accessible to the represented person or their closest family member.

Part F: Outcomes Experienced by Represented Persons and Families (ToR 5)

  1. Where a person who lacks capacity may be subject to restrictive practices – chemical, environmental, or physical restraints – the Tribunal may make an order appointing a guardian to give or withhold consent to those practices. In residential aged care, chemical restraint through psychotropic medication is the most common form.

  2. A practical difficulty has developed in distinguishing a restrictive practice from a medical treatment decision. There is a trend for clinicians to rely on the medical treatment decision-making framework – including the authority of a ‘person responsible’ under section 110ZD of the Act – to administer such medication. The Tribunal has recognised that some restraints may fall within the definition of ‘treatment’ while others do not, and that the question turns on the circumstances of each case (see MS [2020] WASAT 146). Medication used to restrain rather than to treat is often not medical treatment at all, and does not fall within that decision-making framework; it is in substance a restrictive practice requiring guardianship authorisation.

  3. The Committee may wish to consider whether clinicians should receive clearer guidance on this distinction, and whether the Act should be amended to define, or to elaborate upon, the difference between a medical treatment decision and a restrictive practice in this context. Where consent to chemical restraint is sought, the person giving consent should also receive the information necessary to make an informed decision, including whether the medication is being prescribed off-label and any elevated risks for the particular person.

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Financial Depletion

  1. My experience includes matters in which the assets of vulnerable persons have been depleted by persons in positions of trust. This can occur through misuse of enduring powers, redirection of pension income, or failure to account for NDIS or other funding. The current oversight framework may not detect financial exploitation until significant harm has occurred.

  2. The Committee may wish to consider whether the Act should impose more rigorous financial reporting obligations on attorneys and administrators, and whether there should be a streamlined mechanism for the Tribunal to order production of financial records where exploitation is alleged.

Part G: Oversight of Guardians and Administrators (ToR 6)

Monitoring After Appointment

  1. Once a guardian is appointed, there is no systematic mechanism for monitoring whether they are discharging their duties. The system relies on third parties – typically hospitals or distressed family members – to identify guardian failure. There is no check-in call, no visit, and no requirement for the guardian to confirm they have taken up their responsibilities.

  2. The Committee may wish to consider whether there should be a mandatory initial reporting obligation within 28 days of appointment, requiring the guardian to confirm that they have made contact with the represented person and familiarised themselves with the relevant arrangements.

NDIS Interface

  1. The guardianship system and the NDIS operate in parallel but with inadequate coordination. Where a represented person has a substantial NDIS plan and a single nominee has sole control of that plan, the potential for financial mismanagement is significant – particularly where the participant is non-verbal and unable to self-advocate. The Committee may wish to consider whether the Act should be amended to refer expressly to the appointment of an NDIS decision-maker as an explicit function that a guardian or administrator may be authorised to exercise.

Part H: Role and Conduct of the State Administrative Tribunal (ToR 7)

  1. I acknowledge the volume of work undertaken by the Tribunal’s guardianship and administration division. With approximately 7,500 hearings per year and first-instance hearings typically lasting one hour before a single Member, the Members and staff of the Tribunal operate under significant pressure. The observations that follow are directed at systemic patterns and are offered in a spirit of constructive engagement with the Committee’s inquiry.

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Notification Processes

  1. The Tribunal’s notification processes depend on information provided by applicants, who may have an interest in excluding certain family members from the proceedings. Where notification fails to reach an affected person, orders may be made without that person’s knowledge or participation.

  2. The Committee may wish to consider whether applicants should be required to provide a statutory declaration listing all known close relatives of the represented person and their contact details, with penalties for false or incomplete declarations.

Interim Appointment of the Public Trustee

  1. Section 65 of the Act is an emergency provision. Where it appears to the Tribunal that a person may require an administration order, and that it is necessary to make immediate provision for the protection of the person’s estate, the Tribunal may, pending the final determination, exercise its powers to make that provision – in practice, by appointing the Public Trustee as administrator on an interim basis. My concern is that the threshold is low, that the order may be made with limited opportunity for the proposed represented person or their family to respond, and that control of the person’s finances passes to the Public Trustee before any final determination. The burden then falls on those affected to seek to have the interim provision revisited.

  2. The Committee may wish to consider whether an interim appointment under section 65 should be subject to an automatic return date within 21 days – for example, a short hearing of around 30 minutes to evaluate where matters stand, including whether the person who is the subject of the interim appointment has been given adequate resources for day-to-day living – or some similar mechanism.

Volume and Resources

  1. The ratio of approximately 7,500 annual hearings to available Tribunal resources creates tension between thoroughness and efficiency. I submit that the guardianship division requires additional resources commensurate with its volume and the significance of its decisions.

The Expressed Wishes Principle

  1. Section 4(7) of the Act requires the Tribunal, as far as possible, seek to ascertain the views and wishes of the person concerned as expressed, in whatever manner, at the time, or as gathered from the person’s previous actions. Difficulties arise in practice: the represented person may not participate in the hearing; expressed wishes may vary depending on who is present; and clearly documented pre-incapacity wishes may be at risk of displacement by less reliable post-incapacity statements.

  2. The Committee may wish to consider whether the Act should create a hierarchy of wishes, giving primacy to documented pre-incapacity wishes unless there is clear evidence of change, and requiring the Tribunal to make specific findings about the circumstances in which post-incapacity wishes were ascertained.

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Suitability Assessments

  1. Where a proposed guardian or a person with significant influence over the represented person has a history of violence, intimidation, or coercive behaviour, the Act does not currently create a presumption against appointment. The Committee may wish to consider whether the Act should include such a presumption, and whether the Tribunal should be required to make specific findings about suitability where concerns about violence or intimidation are established.

Family Disputes and Declarations of Interest

  1. The guardianship system can be used tactically in the context of family property or control disputes. The system does not currently require applicants to disclose financial interests in the outcome of the application. The Committee may wish to consider whether applicants should be required to make a declaration of interest, disclosing any financial benefit they receive from the represented person, any interest in the represented person’s property, and any family disputes that may be motivating the application.

Geographic and Cultural Barriers

  1. The guardianship system covers one of the largest jurisdictions by area in the common law world, yet the Tribunal sits in Perth. For families in regional and remote Western Australia, participation in hearings is difficult, access to legal representation is limited, and the availability of services to give effect to guardianship orders may be constrained. The Committee may wish to consider whether the Tribunal’s guardianship division should sit periodically in regional centres, and whether the Act should require specific consideration of the represented person’s connection to country, community, and place when accommodation decisions are made.

Conduct of Video Hearings

  1. Where all participants attend by video or telephone, the Member nonetheless sits in the physical hearing room. On the screen seen by the other participants, the hearing room occupies most of the frame and the Member appears as a small figure seated at the bench. The camera position requires the Member to look up towards it, producing poor eye contact and weak communication by video.

  2. The Committee may wish to consider whether, in hearings conducted entirely by video or telephone, Members should conduct the hearing from their office or a desk using a standard webcam positioned at eye level, rather than from the hearing room. A conventional video set-up would improve eye contact and the quality of communication between the Member and the participants.

Caregiver Burnout

  1. Carer burnout warrants the Committee’s attention. Where a primary caregiver collapses under the weight of caring, those who have obstructed support arrangements sometimes rely on that collapse to argue that the carer is unsuitable, when in truth the

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carer has given so much that they have reached burnout. Members often recognise this dynamic and disregard the criticism, but it is a trend I have observed developing.

Part I: Cross-Cutting Observations

  1. Three cross-cutting themes emerge from my experience.

  2. Power imbalance. The guardianship system contains structural power asymmetries that it does not adequately address. In practical terms, aged care facilities can control accommodation and clinical relationships, even where other substitute decision-makers are formally in place. Family members can often control access to the represented person and engineer estrangement. Hospitals can use the system to resolve discharge disputes. In each case, the person or institution with structural power can use the guardianship system to entrench that power, and the system’s procedural framework – interim orders, compressed timeframes, and default to institutional appointments – can facilitate rather than resist that dynamic.

  3. Reactive, not preventive. The system often responds to crises rather than preventing them. There is no community-based early identification mechanism, no mandatory reporting framework for carer distress, and no proactive contact with persons subject to enduring powers.

  4. Restrictive practices and consent. The intersection of the guardianship system and the framework for consent to restrictive practices warrants specific attention. Where chemical restraint is administered as though it were a medical treatment decision, the distinction between a restrictive practice and medical treatment must be clear, and the protections surrounding consent must be robust.

Part J: Summary of Recommendations

  1. I respectfully make the following recommendations for the Committee’s consideration. The paragraph references indicate where each recommendation is discussed in the body of this submission.

Office of the Public Advocate

R1. That OPA investigators adopt, as a matter of general principle, a balanced approach to interviewing witnesses, making efforts to hear from those identified by the applicant, the subject, and any interested parties, rather than relying mainly on the applicant. (see paragraph 9)

R2. That interviews with the subject of an application be conducted in a neutral setting, free from the presence of persons with an interest in the outcome. (see paragraph 9)

R3. That OPA investigation reports be subject to periodic external quality audit, and that a dedicated ombudsman for guardianship and administration be available rather than relying on the general Ombudsman of Western Australia. (see paragraph 17)

R4. That investigation reports be completed and served at least three working days before the hearing date. (see paragraph 11)

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R5. That the Office of the Public Advocate establish a secure online portal, with levels of access that vary according to the role of the user, recording the decisions made by delegated guardians and the reasons for them, accessible to represented persons, family members, and medical practitioners according to their role. (see paragraph 13)

Public Trustee

R6. That the Public Trustee be required to make reasonable efforts to meet with each represented person, in person or by video, within three months of appointment, and to maintain periodic direct contact thereafter. (see paragraph 15)

R7. That, before the Tribunal decides whether to appoint the Public Trustee as administrator, the Public Trustee provide an estimate of its likely fees for the estate, so that the cost of administration can be weighed against the size and circumstances of the estate; where a longer prediction is impractical, the estimate may relate only to the first year of administration. (see paragraph 18)

R8. That the Public Trustee be required to provide annual statements directly to represented persons or their closest family member. (see paragraph 27)

Dispute Resolution and Complaints

R9. That the Act provide a streamlined dispute resolution mechanism for joint guardians, such as mandatory mediation, before formal Tribunal proceedings are required. (see paragraph 20)

R10. That the Act expressly protect persons who make aged care complaints from having those complaints used as evidence of unsuitability in guardianship proceedings. (see paragraph 22)

State Administrative Tribunal

R11. That applicants be required to provide a statutory declaration listing all known close relatives of the represented person and their contact details, with penalties for false or incomplete declarations. (see paragraph 38)

R12. That an interim appointment of the Public Trustee under section 65 be subject to an automatic return date within 21 days – for example, a short hearing to evaluate where matters stand, including whether the subject of the interim appointment has adequate resources for day-to-day living. (see paragraph 40)

R13. That the Tribunal be provided with additional resources commensurate with its volume and the significance of its decisions. (see paragraph 41)

R14. That the Tribunal’s practice directions prescribe minimum service periods for submissions and investigation reports, with a minimum of three working days before the hearing date. (see paragraph 24)

R15. That the Tribunal be required to provide plain-language explanations of the effect of proposed orders and to confirm the participants understand what is being ordered. (see paragraph 26)

R16. That the Tribunal explore options for explaining the process to participants in advance, such as short explanatory videos emailed to applicants, subjects, and interested

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parties, or group intake sessions delivered by designated staff by video. (see paragraph 26)

R17. That the Act create a hierarchy of wishes, giving primacy to documented pre-incapacity wishes unless there is clear evidence of change, and requiring the Tribunal to make specific findings about how post-incapacity wishes were ascertained. (see paragraph 43)

R18. That the Act create a presumption against appointing a proposed guardian or administrator with a history of violence, intimidation, or coercive behaviour, and require the Tribunal to make specific findings about suitability where such concerns are established. (see paragraph 44)

R19. That applicants be required to make a declaration of financial interest in the outcome of the application. (see paragraph 45)

R20. That the Tribunal’s guardianship division sit periodically in regional centres. (see paragraph 46)

R21. That, in hearings conducted entirely by video or telephone, Members conduct the hearing from their office or a desk using a standard webcam at eye level rather than from the hearing room, to improve the quality of video communication with participants. (see paragraph 48)

Oversight and Monitoring

R22. That guardians and administrators be required to file an initial report within 28 days of appointment confirming they have made contact with the represented person and taken up their duties. (see paragraph 34)

R23. That the Act impose more rigorous financial reporting obligations on attorneys and administrators, and provide a streamlined mechanism for the Tribunal to order production of financial records where exploitation is alleged. (see paragraph 32)

R24. That the Act be amended to refer expressly to the NDIS and to make the appointment of an NDIS decision-maker an explicit function exercisable by a guardian or administrator. (see paragraph 35)

Restrictive Practices

R25. That clinicians receive clearer guidance on the distinction between a medical treatment decision and a restrictive practice, and that the Act be amended to define or elaborate upon that distinction; and that, where consent to chemical restraint is sought, the person giving consent receive the information necessary to make an informed decision, including whether the medication is prescribed off-label. (see paragraph 30)

Conclusion

  1. The guardianship and administration system in Western Australia performs a vital function in protecting the rights and welfare of some of the most vulnerable members of the community. The Tribunal, the Office of the Public Advocate, and the Public Trustee

each operate under resource constraints and their commitment to this work is acknowledged.

  1. My experience has revealed systemic patterns that warrant the Committee’s attention. The themes identified in this submission – variable investigation quality, inadequate notification processes, compressed timeframes, the absence of meaningful oversight after appointment, and the reactive nature of the system – are structural features rather than isolated incidents. They reflect a system that is under-resourced for the volume and significance of the decisions it makes.

  2. The Committee’s inquiry represents an opportunity to address these systemic issues. The recommendations in this submission are offered constructively and with respect for the institutions involved. I would be happy to appear before the Committee, and to provide any further information that would assist.

Richard Graham
Principal
Graham & Associates Lawyers
29 May 2026